Medicare and Medicaid Fraud

Violations of laws and regulations governing the Medicare and Medicaid programs may also constitute violations of Federal and State False Claims Acts. Hospitals, nursing homes, doctors, home health care agencies, durable goods providers, pharmacies, and laboratories that seek and receive reimbursement for Medicare and Medicaid funds are government contractors subject to the False Claims Acts. To the extent that these entities receive money from TRICARE, the military’s health insurance program, the Federal False Claim Act is also implicated. In addition, wrongful conduct that defrauds the state of dollars used to insure the health care of public employees may implicate violations of state False Claims Acts.

Healthcare workers and families of nursing home or hospital patients should pay particular attention to the services provided. Not only can this improve the healthcare for patients and loved ones, but it also helps ensure that public monies are properly spent in accordance with law and prudent medical practice.

Billing for services not rendered, misrepresenting the type of goods or services rendered, or misrepresenting the nature of the patient’s illness can trigger liability under the False Claims Act. Likewise, failing to provide correct data on annual hospital or nursing home cost reports that must be provided to the Government may violate the law.

In addition, hospitals and nursing homes that provide substandard care may also violate False Claims Acts.

The following types of conduct should trigger a red flag:

Partially filling prescriptions, but charging as if a full prescription was provided.

Providing kickbacks to a medical provider in order to induce the provider to prescribe certain drugs or use certain products.

Prescribing medications, drugs, or treatment that are not a medically necessary.

Charging Medicare or Medicaid patients a higher rate than others for the same prescription.

Knowingly providing defective products or services.

Falsely diagnosing a more severe ailment than the one the patient actually has, known as “upcoding” a diagnosis, thereby justifying a more expensive drug therapy or other treatment than that which the patient’s health requires.

Inappropriate changes in patients’ prescriptions from one drug to another as a result of kickbacks or for other improper reasons.

Falsely reporting drug research grant information to government agencies.

Changing a diagnosis or treatment code to secure a higher reimbursement from a government program.